Recommended Treatment for Persistent Asthma Using Inhaled Corticosteroids (ICS)
For persistent asthma, the preferred treatment is low-to-medium dose inhaled corticosteroids (ICS) with long-acting inhaled beta2-agonists (LABAs) for adults and children older than 5 years of age. 1
Stepwise Approach to Asthma Management
Step 1: Initial Assessment
- Determine asthma severity based on symptom frequency, nighttime awakenings, SABA use, and activity limitation
- Goals of therapy: symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, SABA use ≤2 days/week, and no interference with normal activity 2
Step 2: Mild Persistent Asthma
- First-line therapy: Daily low-dose ICS 2
- Common ICS options:
- Fluticasone propionate: 88-264 mcg
- Beclomethasone HFA: 80-240 mcg
- Budesonide DPI: 180-600 mcg
- Mometasone DPI: 200 mcg 2
Step 3: Moderate Persistent Asthma
- Preferred treatment: Low-to-medium dose ICS plus LABA 1
- Alternative treatments (if LABA contraindicated):
- Increase ICS within medium-dose range
- Low-to-medium dose ICS plus either leukotriene modifier OR theophylline 1
Step 4: Severe Persistent Asthma
- Daily medication:
- High-dose ICS
- LABA
- If needed: Oral corticosteroids (1-2 mg/kg/day, generally not exceeding 60 mg/day) 1
- Make repeated attempts to reduce systemic corticosteroids while maintaining control with high-dose ICS 1
Age-Specific Considerations
Children 5 Years and Older
- Same approach as adults with preference for ICS+LABA combination for moderate persistent asthma 1
- Consultation with asthma specialist recommended for severe persistent asthma 1
Children Under 5 Years
- For children 1-8 years: Budesonide nebulizer solution is FDA-approved 1
- For children 4 years and older: Fluticasone DPI and salmeterol DPI are FDA-approved 1
- For children 2-6 years: Montelukast 4 mg chewable is approved (based on safety rather than efficacy data) 1
- For young children, the use of combination therapy is prudent when goals are not attained with low or lower range of medium doses of ICS 1
Important Clinical Considerations
Efficacy
- ICS are the cornerstone of maintenance therapy for persistent asthma 2
- ICS suppress virtually every step in the inflammatory process of asthma 3
- Regular use of ICS can reduce asthma hospitalizations by up to 80% and significantly reduce fatalities 4
Dose-Response Relationship
- The dose-response curve to ICS is relatively flat 5
- 80-90% of maximum therapeutic benefit is achieved with standard doses (200-250 μg of fluticasone propionate or equivalent) 6
- High starting doses of ICS provide no additional clinical benefit in most efficacy parameters compared to low or moderate doses 7
Combination Therapy
- Adding a LABA to low-medium dose ICS is more effective than doubling the ICS dose for moderate persistent asthma 1
- Evidence does not support using a third long-term-control medication added to ICS and LABA to avoid systemic corticosteroids in severe persistent asthma 1
Safety Considerations
- Monitor for potential steroid side effects: delayed growth, increased blood pressure, osteoporosis, adrenal suppression, and cataracts 2
- Prevent oral candidiasis by rinsing mouth after ICS use 2
- LABAs should never be used alone for asthma management due to increased risk of asthma-related death 2
Common Pitfalls to Avoid
Using LABAs as monotherapy: LABAs should never be used alone for asthma management due to increased risk of asthma-related death 2
Excessive ICS dosing: High starting doses of ICS provide no additional clinical benefit in most cases but increase risk of adverse effects 7
Inadequate follow-up: After initiating ICS therapy, patients should be assessed for symptom control within 2-6 weeks 2
Poor inhaler technique: Ensure proper inhaler technique - MDIs require coordination between actuation and inhalation (often improved with spacer devices), while DPIs require a rapid, deep inhalation 2
Not considering step-down therapy: Once asthma stability is achieved, titrate the dose downwards to minimize potential side effects 2